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KEY POINTS

The risk of nosocomial pneumonia is considerably higher in the subset of ICU patients treated with mechanical ventilation, with an incremental risk of about 1% per day of ventilation.

Ventilator-associated pneumonia (VAP) is associated with mortality in excess of that caused by the underlying disease alone, particularly in case of infection due to high-risk pathogens, such as Pseudomonas aeruginosa and Acinetobacter spp and when initial antibiotic therapy is inappropriate.

The predominant organisms responsible for infection are Staphylococcus aureus, P. aeruginosa, and Enterobacteriaceae, but etiologic agents differ widely according to the population of hospital patients, duration of hospital stay, and prior antimicrobial therapy.

Although appropriate antibiotics may improve survival in patients with VAP, use of empirical broad-spectrum antibiotics in patients without infection is potentially harmful, facilitating colonization and superinfection with multiresistant microorganisms. Any strategy designed to evaluate patients suspected of having developed VAP therefore should be able to withhold antimicrobial treatment in patients without pneumonia.

Because even a few doses of a new antimicrobial agent can negate results of microbiologic cultures, pulmonary secretions in patients suspected of having developed VAP always should be obtained before new antibiotics are administered.

Quantitative techniques, when performed before introduction of new antibiotics, enable physicians to identify most patients who need immediate treatment and help to select optimal therapy in a manner that is safe and well tolerated.

Empirical treatment of patients with VAP should be selected based on available epidemiologic characteristics, information provided by direct examination of pulmonary secretions, intrinsic antibacterial activities of antimicrobial agents, and their pharmacokinetic characteristics.

Once the microbiologic data become available, antimicrobial therapy should be reevaluated in order to avoid prolonged use of a broader spectrum of antibiotic therapy than is justified by the available information. For many patients, including those with late-onset infection, the culture data will not show the presence of highly resistant pathogens, and in these individuals, therapy can be narrowed or even reduced to a single agent in light of the susceptibility pattern of the causative pathogens without risking inappropriate treatment.

Some very simple, no-cost measures, such as avoiding nasal insertion of endotracheal and gastric tubes, maintaining the endotracheal tube cuff pressure above 20 cm H2O to prevent leakage of bacteria around the cuff into the lower respiratory tract, removal of ventilator tubing condensates with minimal exposure to patients, placement of ventilated patients in a semirecumbent position when enteral nutrition is used, providing adequate oral hygiene with an antiseptic such as chlorhexidine, as well as avoiding unnecessary sedation, may have an impact on the frequency of VAP.

Ventilator-associated pneumonia (VAP) remains a major cause of mortality and morbidity despite the introduction of potent broad-spectrum antimicrobial agents, major advances in the management of ventilator-dependent patients admitted to ICUs, and the use of preventive measures, including the routine use of effective procedures to disinfect respiratory equipment. Rates of pneumonia are considerably higher among patients hospitalized in ICUs compared with those in hospital wards, and ...